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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Noperty FACILITY ID# n SERVICE REQUEST# <br /> v <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FAciuTy NAME <br /> SITE AD RESS --K4 _ <br /> Street Number Dlrocfior, Name <br /> Zip Code <br /> HOME ori UNG ADDRESS (If Different from Site Address) Z 5 b <br /> Street NumberStraot Name <br /> CIS 1' / \/ +$TATE ZIP <br /> t� C� � L a �'15'Z" '2- <br /> PHONE#1 EXT. APN# <br /> LAND USE APPLICATION# <br /> (916) L, "Z rvz> <br /> PHONE#2 EXT. BQS DISTRICT LOCATION COLtE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I� <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT• <br /> n a Ib bat-\3cx� I <br /> HOME or MAILING ADDRESS FAX# <br /> 3 1 '- -o G aa., -4 1 -) 0 (cl I b) b=3 I - <br /> CITY ,® STATE LP L' <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'SSIGNATURE-,::�� ID��/ -S/ LDATE: ©Z�D3105'� <br /> PROPERTY/BUSINEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT r-fp l t,V- <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Tire <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. A A— <br /> ,q <br /> TYPE OF SERVICE REQUESTED: "�� �-�l c L - ct <br /> )� <br /> COMMENTS: r ^ , n(, <br /> FN�RO/V/N COU <br /> ry <br /> to�! `,y <br /> F� <br /> APPROVED BY: / EMPLOYEE#: 7-? DATE: ` S- <br /> ASSIGNEDTO: EMPLOYEE##: �3 j DATE: Z / <br /> Date Service Compl ted (if already completedy SERACE CODE: G�6 P/E: <br /> Fee Amount: Amount Paid c `� <br /> ��� ac I Payment Date <br /> nvoic:# Received By:,Payment Type <br /> REVEHD SED48-01-0255-0 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> I <br />